ati health assessment test bank

ati health assessment test bank Related

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A 45-year-old woman is at the clinic for a mental health assessment. When giving her the Four Unrelated Words Test, the nurse would be concerned if the patient:

  • A. Could not give four unrelated words within 5 minutes.
  • B. Could not give four unrelated words within 30 seconds.
  • C. Could not recall four unrelated words after a 30-minute delay.
  • D. Could not recall four unrelated words after a 60-minute delay.
Correct Answer: C

Rationale: The correct answer is C because the inability to recall four unrelated words after a 30-minute delay indicates potential issues with short-term memory retention, which is concerning for cognitive impairment or memory disorders. This delay allows for the consolidation of memory, so failure at this point suggests a more significant problem compared to immediate recall.

A: Not being able to give four unrelated words within 5 minutes may indicate some difficulty, but it does not necessarily indicate a severe issue as more time is typically allowed for this task.
B: Inability to give four unrelated words within 30 seconds could be due to various factors such as anxiety or processing speed, but it does not necessarily indicate a memory issue.
D: Not being able to recall four unrelated words after a 60-minute delay is expected to be more challenging than a 30-minute delay, so this alone does not raise as much concern as failing the 30-minute delay test.

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A nurse is caring for a patient who is post-operative following a knee replacement. Which of the following should the nurse prioritize in the post-operative care plan?

  • A. Pain management.
  • B. Encouraging early ambulation.
  • C. Administering IV antibiotics.
  • D. Monitoring for signs of deep vein thrombosis.
Correct Answer: B

Rationale: The correct answer is B: Encouraging early ambulation. Early ambulation helps prevent complications such as blood clots, improves circulation, aids in lung expansion, and promotes faster recovery. Pain management is important but encouraging mobility is a priority. Administering IV antibiotics is not necessary unless there is an infection present. Monitoring for signs of deep vein thrombosis is important but encouraging ambulation is a proactive approach to prevent its occurrence.

Which of the following is an example of a secondary prevention activity?

  • A. Routine immunizations
  • B. Health screenings such as mammograms
  • C. Smoking cessation programs
  • D. Health education on healthy eating
Correct Answer: B

Rationale: The correct answer is B, Health screenings such as mammograms, because secondary prevention focuses on early detection and treatment of diseases to prevent progression. Health screenings help identify conditions at early stages, allowing for timely intervention. Routine immunizations (A) are considered primary prevention as they prevent diseases from occurring. Smoking cessation programs (C) and health education on healthy eating (D) are examples of primary prevention, as they aim to prevent the development of diseases by promoting healthy behaviors.

A nurse is teaching a patient with a history of hypertension about lifestyle modifications. Which of the following statements by the patient indicates the need for further education?

  • A. I will monitor my blood pressure regularly.
  • B. I will take my medication as prescribed.
  • C. I can stop taking my medication once my blood pressure is normal.
  • D. I will reduce my sodium intake.
Correct Answer: C

Rationale: The correct answer is C because it indicates a misunderstanding about hypertension management. Patients should continue taking medication even if blood pressure is normal to prevent future complications. Monitoring blood pressure regularly (A) is important for tracking progress. Taking medication as prescribed (B) is crucial for controlling blood pressure. Reducing sodium intake (D) helps lower blood pressure. Choice C is incorrect as stopping medication prematurely can lead to uncontrolled hypertension.

A nurse is assessing a patient who is experiencing shortness of breath and a cough that produces thick, green sputum. Which of the following conditions should the nurse be most concerned about?

  • A. Asthma.
  • B. Bronchitis.
  • C. Pneumonia.
  • D. Pulmonary embolism.
Correct Answer: C

Rationale: The correct answer is C: Pneumonia. The patient's symptoms of shortness of breath and cough with thick, green sputum suggest an acute infection in the lungs. Pneumonia is characterized by inflammation and infection of the lung tissue, leading to symptoms such as productive cough, shortness of breath, and sputum production. It is a serious condition that requires prompt treatment with antibiotics.

A: Asthma typically presents with wheezing, chest tightness, and shortness of breath triggered by certain stimuli, but not usually with thick, green sputum.
B: Bronchitis is inflammation of the bronchial tubes, characterized by cough with clear or slightly discolored sputum, not typically thick and green.
D: Pulmonary embolism is a blockage in the arteries of the lungs, causing sudden shortness of breath and chest pain, but not usually associated with green sputum production.

The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess skin temperature?

  • A. Palpation
  • B. Auscultation
  • C. Inspection
  • D. Use of a thermometer
Correct Answer: A

Rationale: The correct answer is A: Palpation. Palpation involves using the hands to touch and feel the skin to assess its temperature accurately. This technique allows the nurse to detect variations in temperature more effectively compared to visual inspection (Choice C) or listening with a stethoscope (Choice B). Using a thermometer (Choice D) may also provide a precise measurement, but palpation allows for a more comprehensive assessment of skin temperature by considering factors such as localized warmth or coolness.

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